Introduction to Cardiac Disease: Rehab Goals to Prevent Future Complications (14:54)
Robin Gilbert asks audience members to share their healthcare discipline. Topics will include cardiac disease, diagnosis qualifying for cardiac rehabilitation, and patient process from diagnosis and acute care to rehab. Gilbert has a background in emergency nursing and does not represent any pharmaceutical companies.
Cardiac Disease Paradigm Shift (03:19)
Heart disease patients are living longer and the healthcare system is focusing more on the care continuum, including lifestyle therapies and preventative care. Only a fraction of eligible Americans participate in cardiac rehab; barriers include underserved populations, under referrals, and logistics.
What Happens in Cardiac Rehab? (10:07)
Cardiac rehab is a medically supervised, referral program focusing on lifestyle modification to improve patient outcomes, including functional capacity and quality of life. It includes modifiable risk factor assessment, secondary prevention program engagement, pharmacological management, and early outpatient rehabilitation. Gilbert discusses cost-benefit justification challenges.
Patient Case 1 (03:59)
A 58 year old diabetic, hypertensive, and obese man had a recent stent placement. He presents to the ED with band pressure and shortness of breath; nitro relieves the pain and his EKG is unremarkable. Hear possible non-cardiac co-morbidities.
Acute Coronary Syndrome (17:59)
Learn to assess for acute myocardial infarction with ST segment elevation, without ST segment elevation, and unstable angina. Gilbert discusses modifiable risk factors, explains how to read an EKG, and discusses monitoring troponin and CK-MB levels. Hear why unstable angina patients cannot attend cardiac rehab.
Emergency Department MI Protocol (14:26)
Healthcare professionals should get a baseline EKG within ten minutes and be prepared for arrhythmias. Administer aspirin, nitrates and fentanyl and prepare IV access. Gilbert explains angioplasty, stent placement, CABG and intra-aortic balloon pump procedures. PCI provides greater post-op mobility than CABG.
Cardiac Rehab Eligibility (06:27)
Patient 1 has non-STEMI multi-vessel disease and stenosis of his circumflex branch; he is treated with stents. Accepted diagnoses include heart attack, CABG, stable angina, heart valve repair, angioplasty, coronary stent, heart-lung transplant, and chronic stable heart failure.
Cardiac Rehab Procedures (09:59)
Patients must have an exercise prescription including modalities, frequency, and duration. Gilbert explains risk stratification classifications, provides exercise examples, and explains METS and the Borg Scale.
Cardiac Rehab Phases (07:40)
Phase one starts in acute care, has no reimbursement, and includes ADLs. Phase two is covered by Medicare; phase three is not. Gilbert discusses ways to retain patients while avoiding expensive copays in phase three.
Stress Testing and Patient Intake (12:37)
A nurse practitioner can refer patients to cardiac rehab; exercise prescriptions include modalities, frequency, and intensity. Gilbert discusses exercise cardiography, nuclear imaging, and pharmacologic stress testing. She goes over ITPs, risk stratification tools, and patient progress monitoring.
Patient Case 2 (11:47)
Gilbert discusses exercise plans for heart transplant patients. A 66 year old diabetic woman is diagnosed with CHF. Heart failure is either systolic or diastolic; left ventricular systolic dysfunction with reduced ejection fraction is most common. Learn about CHF complications.
Heart Failure Acute Care Interventions (15:25)
Gilbert discusses anticoagulants and LVADs, including LVAD complications. Post-PCI patients are not eligible for IDC for 90 days, but are sent home with life vests containing defibrillators. Learn about cardiac resynchronization therapy for patients with ventricular conduction delays.
Cardio MEMS Implant, Cardiac Rehab and CHF (09:37)
Gilbert describes a new heart failure system allowing doctors to remotely monitor patient pulmonary artery pressure and heart rate. Medicare referral criteria includes patient stability, left ventricular EF of 35% or less, and falling between II and IV symptoms. Gilbert explains the LACE Index for predicting readmissions.
Patient Case 3 (05:10)
A 73 year old man is under stress and has had an MI and stent. Gilbert explains the CHADS2-VASc score as it predicts embolization risk in atrial fibrillation patients. Scores greater than two benefit from anti-coagulation therapy.
Gilbert explains the significance of PACs and PVCs in a fresh MI; PVCs can deteriorate into sustained V-tach and v-fib. Learn about causes and treatments for supraventricular tachycardia including cardioversion, bradycardia, and heart blocks. Gilbert recites a poem to remember heart block types.
Patient Case 4 (05:17)
Gilbert explains how to identify axis deviation in QRS complexes on an EKG. A 70 year old man has headaches and sustained hypertension, causing left ventricular hypertrophy. His EKG reveals left axis deviation.
Pacemakers and ICDs (13:00)
Gilbert discusses using transcutaneous pacemakers in an emergency situation. View a short video of the Micra Transcatheter Pacing System. Learn about ICD indications and use. Gilbert explains how cardiac ablation is used to manage tachyarrhythmias.
Patient Case 5 (12:13)
An 81 year old man has had a surgical aortic valve replacement. Learn about valvular disease and surgical aortic valve replacement, view a video on the TAVR procedure and learn about post-operative monitoring. The patient develops an AV block and has a pacemaker installed.
Chronic obstructive pulmonary disease patients have diminished pulmonary capacity; learn about severity categories and spirometry testing. Gilbert explains emphysema and chronic bronchitis differences and discusses patient education and compliance. Treatments include bronchodilators, pulmonary rehabilitation, smoking cessation, and lung volume reduction surgery.
Patient Case 6 (10:25)
Learn about signs and treatment for respiratory distress and failure. COPD patients can also develop acute respiratory distress syndrome, a separate diagnosis. Gilbert discusses VQ mismatching causes. A 64 year old man has respiratory distress, and is febrile, tachycardic, and tachypnic.
Gilbert distinguishes between type I and II and discusses type II medications. Learn about the "3 Ps," ketoacidosis and metabolic acidosis, including lab values. Exercise is generally beneficial but peripheral neuropathy can cause musculoskeletal pain. Hear sample guidelines for hyper- and hypoglycemic situations.
Patient Labs (12:21)
Gilbert discusses looking at patient lab numbers, medications and clinical symptoms. Rapid changes in patient status can include hypoxia, hypoglycemia, hypovolumia or arrhythmia. MCV determines RBC size and anemia; hear possible causes of platelet and WBC changes, electrolyte imbalances, and albumin changes.
Blood Gases (07:52)
Gilbert explains normal pH, CO2, PAO2 and bicarb values, and how to treat abnormal values. Hear examples of values indicating respiratory acidosis, respiratory alkalosis, metabolic acidosis and metabolic alkalosis.
Cardiac Rehab Patient Assessment (06:17)
Post-PCI challenges include depression, medication compliance, and financial concerns. The Duke Activity Index determines functional capacity through self-reporting. Learn about CESD and PHQ self-rated depression tests, and quality of life index tools.
Cardiac Rehab Patient Education and Outcomes (09:28)
Gilbert discusses multi-disciplinary approaches to changing patient nutrition and lifestyles. She goes over measurable clinical, behavioral, health, service, and evidence-based program quality outcomes.
Secondary Prevention Programs and Patient Rewards (04:59)
Cardiac rehab has decreased readmissions and ED visits. Lack of reimbursement is a roadblock for hypertension and diabetes prevention programs. Participants discuss ways to generate more traffic to cardiac rehab programs and celebrate patient progress.
Emergencies, Insurance and Reimbursement (11:40)
Patients can develop arrhythmias, syncopies, or seizures. AACVPR requires policies on certain diagnoses, code team activation, and protocol from onset to resolution. Gilbert recalls challenges during mock codes at her facility and discusses Medicare requirements for cardiac rehab facilities, documentation, and CPT codes.
Emailed Questions and Preparing for Certification (08:34)
Gilbert explains the difference between heart failure with decreased and preserved EF and discusses arrhythmia causes. She goes over quality outcome measures, the medical director role, staff competencies, and emergency and clinical outcome policies required for certification.
Patient Outreach (06:52)
Only a fraction of the two million eligible Americans are participating in cardiac rehab programs. Gilbert discusses ways to use technology to engage patients and improve compliance. She suggests using facilities as after-hours fitness centers.
Patient Cases (23:19)
Hear symptoms and clinical assessment for bradycardia, atrial fibrillation, narrow complex tachycardia, anterior lateral MI, Wolff-Parkinson-White syndrome, hypokalemia, broken heart syndrome, cocaine induced MI, PVC, pulmonary embolism, and occlusion requiring a CABG.
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